How should anticoagulation be managed in a patient with glioblastoma multiforme who is on a direct oral anticoagulant for atrial fibrillation and the anticoagulant has been held?

Management of Held DOAC in GBM Patient with Atrial Fibrillation

Resume the DOAC as soon as neurosurgically safe—typically 2-3 days after high-bleeding-risk neurosurgical procedures—without heparin bridging, as bridging increases bleeding risk without reducing thromboembolism. 1

Immediate Assessment

When the DOAC has been held, determine:

• Time since last DOAC dose and which specific agent (apixaban, rivaroxaban, edoxaban, or dabigatran) 2
• Reason for holding: Was this for planned neurosurgery, active intracranial bleeding, or other indication? 1
• Current bleeding status: Is there ongoing hemorrhage or has hemostasis been achieved? 1
• Renal function (creatinine clearance): This determines DOAC elimination time and resumption safety 3, 4
• Stroke risk (CHA₂DS₂-VASc score): Score ≥2 in men or ≥3 in women mandates long-term anticoagulation 1, 3

Critical Decision: When to Resume Anticoagulation

For Neurosurgical Procedures (High Bleeding Risk)

Resume DOAC 2-3 days postoperatively if there is no ongoing bleeding or surgical contraindication 1. Intracranial neurosurgery is classified as very high bleeding risk, requiring longer interruption times preoperatively (3-5 days depending on agent and renal function) and delayed resumption 1.

If Active Intracranial Bleeding Occurred

• Anticoagulation is contraindicated until the bleeding source is identified and definitively resolved 1
• For spontaneous intracranial hemorrhage, anticoagulation remains contraindicated unless the underlying cause has been reversed 5
• Do NOT restart DOAC if there is ongoing bleeding or hemodynamic instability 1

Bridging Strategy: What NOT to Do

Bridging with heparin (UFH or LMWH) is NOT recommended when resuming DOACs after procedures 1. The evidence is clear:

• Bridging increases bleeding risk without reducing thromboembolism 1
• Multiple guidelines explicitly recommend against bridging for DOAC interruption 1, 3, 2, 6
• The only exceptions are mechanical heart valves or recent stroke/TIA (within days), which don't apply to routine GBM management 1

Resumption Protocol

Standard Resumption Timeline

Once hemostasis is confirmed and no surgical contraindication exists:

• Low bleeding risk procedures: Resume DOAC ≥6 hours postoperatively 1
• High bleeding risk procedures (including neurosurgery): Resume DOAC 2-3 days postoperatively 1, 2

Dosing Schedule Based on Regimen

• Twice-daily regimen (apixaban, dabigatran): Resume the evening of resumption day 1
• Once-daily morning regimen (rivaroxaban, edoxaban): Resume the next morning 1
• Once-daily evening regimen: Resume that evening 1

Temporary Prophylactic Anticoagulation

If DOAC resumption must be delayed beyond 2-3 days due to ongoing bleeding concerns:

• Consider prophylactic-dose LMWH (not therapeutic bridging) for venous thromboembolism prophylaxis only 1
• Reassess daily for ability to resume therapeutic DOAC 1

Special Considerations for GBM Patients

Intracranial Bleeding Risk

GBM patients have elevated intracranial bleeding risk due to:

• Tumor vascularity and potential for spontaneous hemorrhage
• Prior neurosurgical intervention
• Possible thrombocytopenia from chemotherapy

However, high stroke risk from atrial fibrillation (CHA₂DS₂-VASc ≥2) still mandates anticoagulation unless there is active bleeding or recent spontaneous intracranial hemorrhage 1, 3, 5.

DOAC Selection

DOACs remain preferred over warfarin even in GBM patients because they reduce intracranial hemorrhage risk by 50% compared to warfarin 3, 5, 7. This is particularly important in patients with brain tumors 1, 3.

Dose Verification

Do NOT arbitrarily reduce DOAC dose unless the patient meets specific criteria 1, 3:

• Apixaban: Reduce to 2.5 mg twice daily only if ≥2 of: age ≥80 years, weight ≤60 kg, creatinine ≥1.5 mg/dL 1, 3
• Other DOACs: Follow renal function-based dosing per drug labeling 3

What NOT to Do: Critical Pitfalls

• Do NOT add aspirin or other antiplatelet therapy to DOAC for stroke prevention—this increases bleeding without reducing thromboembolism 1, 3, 7
• Do NOT bridge with therapeutic heparin when resuming DOAC 1, 2, 6
• Do NOT measure DOAC levels before resumption in routine cases—this is unnecessary 1, 2
• Do NOT switch between DOACs or to warfarin without clear indication 1
• Do NOT use bleeding risk scores to decide against restarting anticoagulation—manage modifiable bleeding risk factors instead 1

Monitoring After Resumption

• Assess renal function before resuming and monitor regularly, especially with declining function or age ≥75 years 3, 4
• Evaluate for drug interactions with chemotherapy agents, particularly azole antifungals, diltiazem, or verapamil 3
• Clinical follow-up for signs of bleeding or thromboembolism 3

If Anticoagulation Cannot Be Resumed

If the neurosurgical team determines anticoagulation poses unacceptable bleeding risk:

• Document clear contraindication and timeframe for reassessment 1
• Consider left atrial appendage occlusion as alternative stroke prevention if long-term anticoagulation is contraindicated 1
• Prophylactic anticoagulation only until therapeutic anticoagulation is safe 1